When a player running at full speed collides with a wall, a goal post, or another player, a force may develop equal to hitting a concrete wall at 20 mph. Many injuries and accidents can be prevented with proper officiating, coaching, matching, equipment, facilities, health care, self-control, and conditioning. The maxim of "prevention is better than cure" is nowhere more important than in sports. All too many athletic injuries are unnecessary.

Officiating

Game rules and regulations are designed (a) to preserve the character and spirit of the sport and (b) to protect an athlete from both himself and his competitors by minimizing risk. Without proper officiating and disciplinary action, players loose a fundamental protection based on game experience. Unnecessary violence should never be left unpenalized. It is vital that all officials be both technically and emotionally qualified. Unless players and coaches have confidence in the officials, the officials' decisions will not be respected. The less the respect, the greater the injury incidence and the less the competition will be enjoyed by the participants.

All involved in a sport should be thoroughly disciplined in the rules of the game. These rules should be strictly enforced in practice sessions as well as in official competition. In addition, the doctor must be familiar with the rules and procedures concerning each sport to be alerted to the possible and probable mechanisms of injury. Identical disabilities and injuries have a different effect on different types of athletes. A specific injury may be less important in terms of performance in one position than another: eg, a sprained thumb of a guard as contrasted with that of a center in football.

Coaching

One goal of good coaching is the improvement of skill, as the improvement of performance lowers the incidence of injury. Skill development should be made progressively to allow for physical and functional adaptation. Unaccustomed exercise or jolts can be frequently injurious, always painful, and occasionally fatal. If the incidence of injury is to be minimal, tactics with a high injury risk must be avoided. Blocking and tackling should always be taught to be made with the face up, and the helmet should never be taught to be used as a weapon. When any player shows signs of disability, substitution should be made immediately so that proper evaluation can be made.

In a good preventive program, all injuries should be analyzed as to cause and corrective coaching measures applied. It is the coach's responsibility to see that every player wears the proper type of well-fitting apparel and keeps in optimum physical fitness.

Helpful information by itself does not guarantee compliance. Written instructions and oral recommendations are rarely meaningful by themselves. Effective behavioral change requires reasons for change, motivation, instruction, illustration, individualization, repetitive practice, and insistance. All of these should take into consideration an athlete's attitudes and values.

Matching

Proper matching allows for greater safety, participation, and more equitable competition. In neighborhood programs, as well as in elementary and junior high school programs, players are often grossly overmatched against much faster, larger, stronger, taller, and heavier opponents in contact (collision) sports. If not in the games themselves, then this often happens in practices or scrimmages. Each sport determines the criteria (eg, height in basketball, weight in wrestling). A youth's age and maturation are always a consideration. Bony prominence measurements (eg, the Tipton-Tcheng method) have proven helpful wherein measurements are taken of standing height, chest width and depth, hip width, and ankle width. However, more controlled studies in a variety of sports are needed for accurate matching criteria.

Facilities

Playing-area facilities and field or arena conditions are a fundamental consideration. Is the area carefully maintained for optimal safety conditions? Has care must be taken that spectators are not seated too close to the action? Are obstacles (eg, goal posts, ring ropes) well padded, and is the playing area free from debris and "gopher holes"? Is the ice on the hockey rink even, and are spectators protected from flying sticks and pucks? Is the swimming pool equiped with surface lane markers, underwater lights and lane markers, and is it deep enough for safe diving? In baseball, are the bases firmly but not rigidly fixed to safeguard the sliding baserunner?

Some rock-like artificial turfs are easy to maintain but greatly increase painful strains, contusions, and severe abrasions -- requiring mandatory long sleeves, extra padding, short rubber cleats, etc. The field should be watered down periodically during hot weather to avoid temperature buildup. However, the field should not be so wet as to cause loss of traction; this would be a potential contributing factor in injuries. It should also be noted that when a football player collides with the turf, especially the artificial turf commonly used, after a block or tackle, the impact force is at least twice the velocity of impact.

Disability Prevention

As mentioned, good health care is founded on thorough evaulation and the development of confidence between doctor and trainer, coach, player, and family physician. All should be educated as to the benefits of injury and disability prevention, good nutrition, conditioning, and body heat balance. Towards this end whenever possible, the doctor should attend practice sessions as well as official games, not only to be available to offer professional attention and counsel, but also to witness the cause of injury or potential injury and to try to offer suggestions on preventive measures.

Chronic disability can often be prevented by following established safety principles:

1. Players should never be allowed to play until an injured part is adequately healed. The risk of repeated injury leading to serious chronic disability must be well weighed. When an athlete enters game or practice competition with a minor injury, the part should always be well taped, supported, padded, or wrapped to protect it against further injury. It is well established that when an athlete returns to competition under the influence of a pain killer, the risk to injury aggravation and chronic disability is extremely high.

2. To compensate for joint-ligament weakness, the strength in an injured limb and the opposite limb should be redeveloped to a degree stronger than the pre-injury level. Voluntary resistance exercises, specifically designed for the sport and position involved, are most helpful in developing joint strength. Especially in cases of ligamentous damage, the development of overall muscle power of a limb can increase residual strength to enhance resistance against twists and blows. A knowledge of applied kinesiology is helpful here to better evaluate muscular imbalance.

Conditioning in athletics is one of the most important ways to prevent injuries by strengthening tissues, keeping the joints flexible, improving physiologic tone, reducing excessive weight, and reducing fatigue. To maintain acquired conditioning, each team member and prospective member should be given a regimen for preseason conditioning, and each player should be required to adequately warm up before each competition or practice. As a general rule, at least 3 weeks of practice should be held prior to the first competition. During the off season, two or three moderate workouts a week is usually enough to prevent much deterioration. When an athlete is physically capable of performing a sport with optimal efficiency, he or she can meet both physiologic and biomechanical demands placed upon the body. This is true not only for typical performance demands but also for critical situations.

General Fitness

One of the most important factors in preventing injuries is the development of an appropriate level of physical fitness. Haycock feels that "conditioning is the equivalent of physical fitness". In the last analysis, to be "fit" is to be equal to the demands. But to be physically fit for one sport or position does not imply fitness for another. Yet, a conditioned athlete will have greater endurance, strength, and stamina than the nonathlete.

Certain sports require greater levels of fitness of different anatomic parts, and this must also be realized. A marathoner will traditionally have poor upper body development as compared with a discus thrower who will have superior upper-body fitness.

A low level of physical fitness leads to fatigue that tends to break down the conditioned reflexes involved in physical skills. However, skill alone won't protect an athlete against the effects of over-exertion if activity is carried beyond the limit of his/her level of physical fitness. Conditioning enhances flexibility, agility, speed, endurance, and strength --all safeguards against injury which have positive benefits to one's level of general fitness and performance.

Conditioning Components

To develop good athletic performance, conditioning programs should have four major components:

(1) warm up and stretching,
(2) the development of muscular strength,
(3) the development of joint flexibility, and
(4) the development of endurance (both somatic muscular and cardiorespiratory).

The best protective gear possible should be provided. Each design offers advantages and disadvantages. In contact sports, protective gear is of the utmost importance. Cheap lines are usually inferior in protective quality, but quality equipment is not the answer to preventing injury if it is improperly fitted, poorly adjusted, or has outlived its usefulness, regardless of cost. Ironically, much modern equipment is so cleverly engineered that athletes are developing reckless techniques, resulting in severe forces that would never have been considered years ago with inferior protection (eg, stick tackling and spearing in football).

Clothing and other gear worn by athletes can be divided into two categories: basic clothing and protective equipment. Basic clothing consists of such items as shirts, sweaters, jackets, pants, skirts and dresses, underwear, socks and tights, gloves, and footwear. These items help to protect the skin from injury and often aid in holding interior padding in place. With the increase of female participation in sports, new designs for protective equipment must be created or adapted when established male designs are not satisfactory.

The person who is charged with the responsibility of selecting and purchasing athletic equipment plays a vital role in safeguarding the athlete's health. Usually this is the alert trainer with his rare instinct, as few administrators or even doctors and coaches are as close to the needs of the players as is the trainer. Unfortunately, few standards exist. Much is done by trial and error and by word of mouth among trainers and the powerful "grapevine" in athletics. The market is intensely competitive. Manufacturers offer a plethora of styles and many conflicting claims. The goal is to purchase the best equipment possible, which is usually but not always the most expensive, fit it well, check it constantly and make repairs immediately, see that it is worn in all competition (practice and games), and clean it frequently.

All sports have developed protective equipment uniquely adapted to particular requirements. The need for gloves, catcher's pads and masks, and batting helmets is obvious in baseball. The hockey goalie's bulky padding and fiberglass mask are a must, as is the fencer's mask, and the shin guards used in soccer. Likewise, we see the shoulder pads, arm guards, helmets and face guards used in lacrosse, field hockey goalkeeper toe boots, and fail-safe ski bindings. While space does not permit a discussion of all protective gear utilized in sports, the need, use, and fitting of some models will be briefly explained in this section so that pertinent principles may be underscored.

Corwin warns that an athlete at times may forego protective clothing or padding in the interest of increasing speed or flexibility. This practice must be discouraged.

Design Considerations

Poorly designed protective equipment presents two hazards: it is dangerous in itself and it can instill in its wearer a false sense of security. Williams and Sperryn offer four basic requirements for athletic clothing which are worthy of repetition here. They state that protective clothing should:

1. Provide complete or adequate protection to the appropriate part of the body under the conditions of use. It should withstand any foreseeable impact, and any distortion which may take place under stress should be within clearly defined limits.

2. Be made of such a material as to allow proper cleansing and retain its properties for a reasonable period of time. Protective clothing is not acceptable if it progressively loses its capacity to protect.

3. Be so designed and made as to allow the wearer an appropriate freedom of action and to not interfere with his activities in such a way as to constitute a source of danger to him.

4. Be so designed and made that its use does not in any way constitute a source of danger to anyone with whom the wearer comes into contact. In general, this later requirement should be fulfilled by any item of sportswear.

Adrian also points out the necessity for such features as nonrestrictive movement, nonabrasive and nonirritating characteristics, heat loss and heat retention balance, light weight, and the initial level of protection. For example:

1. Nonrestrictive movement:   Test clothing by having the wearer vigorously swing limbs up and down and across the body, bending side to side, backward and forward, rotating, twisting trunk right and left, reaching high and low, squatting --covering the major joints' full range of motion, especially those concerning typical position postures. Check that tight clothing does not bind at the armpit, elbow, neck, or chest. Undergarments should not creep with vigorous movements. Check shoes by prancing, jumping, stamping, rising on toes, pushing off, making quick turns, and putting the ankle and foot joints through their full range of motion. Check gloves by flexing and extending fingers and palms, then put the wrist through its full range of motion.

2. Nonabrasive and nonirritating characteristics:   Most athletic clothing made today is a blend of manmade and natural fibers which is soft and non-abrasive. Heavy or poorly sewn seams and thick hems, as seen in "bargain" sportswear, often cause chafing. In addition, some clothing which features wash-and-wear nonwrinkle benefits, odor prevention qualities, and water repellency characteristics may be abrasive to sensitive skin. Some athletes may be allergic to wool or sensitive to the chemicals or electrostatic charges within clothing.

3. Heat loss and heat retention balance:   Synthetic materials have a tighter and more elastic weave than natural fibers. They do not allow easy passage of air, and this inhibits heat loss and interferes with proper perspiration evaporation. Because of their low permeability to moisture and air, noniron finishes and waterproofing processing especially inhibit heat loss. Manmade materials used in modern footwear rarely allow for proper air passage; they restrict heat loss, and encourage the growth of fungi and bacteria.

4. Light weight:   The less weight the less effort necessary for activity; however, the low-weight feature must not overlook the need for adequate padding, warming or cooling, and other safeguards. Adrian believes that athletes without lightweight clothing are probably putting out 10% more effort than they would otherwise need.

5. Initial level of protection:   Basic clothing should offer the first level of protection against both extrinsic and intrinsic forces. This protection is made by smooth, nonabrasive clothes covering the skin, protecting against skidding, abrasion, sliding, falling, and colliding irritations.

Skull, Face, and Eye Protection

Protective equipment for the skull, face, and eyes should be so designed that it moves with the head without loosening, is lightweight, and protects the vital areas of the scalp, ears, eyes (without affecting peripheral vision), cheekbones, face, nose, mouth, teeth, chin, and neck.

      SAFETY GLASSES

Safety glasses come in both plastic lenses and heat-treated lenses. The heat-treated lenses are usually preferred because the resin type easily scratches. The bridge of the nose should be cushioned to prevent possible trauma. Temple bars should comfortably wrap around the ears and be stabilized on the head by an elastic band.

      CONTACT LENSES

Contact lenses are available in two sizes. One size (scleral or haptic) covers the entire white of the eye. The other size (corneal) covers only the colored part of the eye. Both hard (acrylic) and soft types are available. Contact lenses offer distinct disadvantages and advantages over conventional spectacles with safety lenses and frames.

The major disadvantages are that in contact sports they may become dislodged and lost, and in several sports, dust or sand often works its way under the lens, becomes trapped, and sets up an irritating abrasion of the cornea. Contributing to this is the fact that after contacts are worn for about a month, the cornea loses some of its normal sensitivity and the early warning sign of pain is diminished. The resulting abrasion may produce corneal scars which contribute to visual loss. It is almost impossible for a swimmer or diver to keep a corneal contact in place, but the scleral type usually can be held by squinting. In addition, contact lenses require frequent removal, cleaning, storage, and reinsertion to avoid irritation or infection. Many ophthalmologists suggest that athletes should allow a 2-month break-in period before competition is tried with contact lenses.

The distinct advantages with contacts are that irregular astigmatism is more readily corrected, peripheral vision is enhanced, and contacts do not cloud up as spectacles do. Another benefit is the tinting attribute of contact lenses that offers special advantages in particular sports. For example, in skiing, a grey or dark blue tint helps to reduce snow and sun glare, while in hockey, a yellow tint reduces ice glare. In wrestling, contacts are possible, and spectacles are not, but even contacts should not be worn unless vision is severely impaired.

      MOUTH PROTECTORS AND FACE GUARDS

One of the most serious problems in athletes has been injuries to the head and face. Doland and Holladay point out that tooth damage runs from 45% to 55% of a body-contact sport squad's injuries. The proper use of mouth protectors in both contact and noncontact sports is invaluable to injury-prevention goals. It is now mandatory that each high school and college football player wear an occlusal and labial protector. However, use is increasing in such sports as basketball, polo, glide flying, hockey, skating, judo, karate, lacrosse, parachuting, skiing, snowmobiling, soccer, surfing, and touch football. It takes the typical athlete about 10 days to get accommodated to wearing a mouth piece, yet the benefits are large.

A face guard is a great asset in deflecting severe blows from the orbital, frontal, and mandibular areas of the face --any of which may result in a fatal injury. Experience has shown that face guards and mouth protection greatly cushion the teeth, lips, cheeks, and reduce jaw fractures and concussion if the condyle head of the lower jaw is jammed posterior-superior against the skull.

Two types of mouth protectors are recommended:

(1) Custom-designed protectors, fitted by a dentist and constructed from a impression mold of the athlete's own teeth. This type offers the best fit, comfort, protection, and affords the best ease of speech and breathing when worn.

(2) Mouth-formed protectors, self-fitted to the individual by clenching the teeth into the protector itself. It is first treated with a chemical or boiled, then impressed and allowed to harden. A third stock-variety type is not recommended, but is available with or without the safety-release helmet strap. Each type must be examined frequently for damage and cleaned daily with a disinfectant.

The effectiveness of mouth protection in cushioning the teeth can be readily shown in the comparative statistics of high school dental injuries as compiled by the American Dental Association. The figures below are rounded:

    1954 --- Face guards and mouth protectors rarely worn 
             (23% of players injured). 



    1955 --- Face guards mandatory, few mouth protectors worn 
             (18% of players injured). 



    1960 --- Face guards mandatory, mouth protectors sometimes worn 
             (12% of players injured). 



    1963 --- Face guards mandatory, mouth protectors mandatory 
             (5% of players injured). 

1. Exterior:   The helmet should have a smooth, slick, firm surface so that it will readily slide when the head strikes the ground rather than stopping abruptly and subjecting the head and neck to a sharp jolt. The face guard should have multiple cross bars, a vertical midline bar, and be designed so it will not protrude so far from the face that it can be easily used as a lever by the competition; the result may be cervical subluxation, dislocation, fracture and/or cord damage. It is important that the face guard's point of attachment to the helmet is strong enough to withstand sharp impact that could split the plastic and cut the player's face.

2. Interior:   A suspension-type helmet or one with effective shock-absorbing padding at the top of the skull must be used to prevent "bottoming"; that is, the helmet forced down onto the skull. In suspension-type helmets, frequent checks should be made to assure that the square knot is tied correctly. As the majority of blows to the head are received laterally, effective padding must be provided in the sides. The helmet should fit snug because much protection is lost when it is loose. Special adaptations must be made for the atypical head which is unusually oval, long, heavy browed, occipitally large, or if the forehead severely slants several degrees.

A well-engineered helmet cannot properly absorb blows if it is improperly adjusted. The basic checks, adapted from those of Craig, are listed below:

1. Entering Check:   The helmet is entered by (a) placing the thumbs in the ear holes and holding the sides of the helmet with the extended fingers, then (b) placing the helmet directly over the head. In one smooth motion, it should be first tilted to the back and then flexed to the front as it is pulled down. If the neck band becomes rolled, roll the helmet forward. The helmet should fit at normal hair length.

2. Crown and Forehead Check:   A properly fitted crown will appear one finger width above the eyebrow. Instruct the player to place his overlapped hands on the middle top of the helmet and exert downward pressure. Undue pressure should not be felt on the top of the head against the rubber crown. If the helmet is too low, all pressure will be felt against the forehead. To check this, stand in front of the player and place your hands on the back of his helmet, with your forearms resting on his shoulders. Ask the player to brace his head against your hands, and note the distance at the front of the suspension. In a proper fit, the suspension will slightly slide on the forehead, yet not leave a large space between the suspension and forehead.

3. Lateral Check:   First do a general visual check, then instruct the athlete to flex his neck and attempt to rotate the helmet. With a proper fit, only a slight turn of the helmet should be noticed, slightly more with the atypical long or oval-shaped head. Then check fit by placing the fingers inside the helmet and along the suspension. Correct excessive lateral room with spacers.

4. Neck Band Check:   The neck band should be snug, yet comfortable. Neck bands, which come in various sizes, allow the helmet excessive forward rotation when too loose. The neck band which comes with the helmet may or may not be appropriate for a good fit. Make all necessary corrective adjustments for proper fit.

5. Chin Strap and Jaw Pad Check:   The four-point chin strap is recommended as it seems to offer additional support by holding the helmet from sliding anterior-posterior. Insure that the straps are adjusted taut and tension is equal bilaterally. A loose chin strap will allow the mouth to open and the mandible to malposition. However, under severe pressure, the strap should release, never lock. The jaw pad, which comes in various sizes, should fit the mandible snugly to prevent the helmet from rocking laterally. Double check to assure that the helmet is well secured.

While "spearing" with the helmet is considered illegal, "butt blocking" by raming with the head should also be sharply discouraged, even if "legal", if serious head and spinal cord injuries are to be prevented. A popular model developed by A. C. Larcher, D.C. helps to neutralize this effect of a hard helmet.

      SHOULDER PROTECTORS

The shoulder girdle is subjected to numerous jolts, probably far more than other areas in football. The pads should be so designed as to offer protection to the deltoid area, the clavicle, and to some degree, the neck.

By necessity, proper engineering must be a compromise between good stability and guaranteed arm mobility --with the helmet, the shoulder-pad apparatus, and the jersey working as a trinity for shoulder protection. The jersey should be porous to allow for heat dissipation, durable, somewhat elastic, and tight to help secure the shoulder pads. The shirt tail should be long enough that it can be pulled from the back and buttoned in the front to prevent slippage.

Shoulder pads are a complicated product of engineering research. They come in various sizes and body arch to meet the needs of different positions. Fit must be done carefully and individually to accommodate for body size, thickness of the neck, and shortness of the neck. A large variety of types exist; eg, low-profile models, externally and internally padded models, and inside and outside cantilever models --all of which receive praise and criticism.

The typical shoulder pad is designed as a right and left half joined by midline lacing to hold the upper and lower halves of the body arches in opposition. The pads should extend over the chest anteriorly and posteriorly to protect the scapulae, supra- and infra-spinatus muscles, as well as the trapezii and rhomboids. The body arches must meet evenly, with the medial portion close to the neck. The lower portions of the body arches should not overlap. Each section is molded over a strap of spring steel which gives the pad its shape. This strip extends anterior-posterior to cover the trapezius area and holds the pad off the shoulder with a shock-absorbing material. Keep in mind that the anterior chest and scapular areas receive the transmitted forces from shoulder blows.

A poorly secured pad results in too much space seen between the medial edge of the pad and the neck, allowing the steel strap to override the acromion and lateral clavicle, subjecting this area to potential trauma. A properly secured helmet and shoulder pads, which do not allow excessive space between neck and pad, also helps to prevent ipsilateral neck skin brusing and the contralateral "nerve stretch syndrome" seen in lateral-flexion neck sprain when the neck meets with a severe blow from the side. A properly fitted helmet and shoulder pads will allow the neck to only partially flex laterally because the temporal portion of the helmet will strike the shoulder pad.

Laterally, a molded padded cup should snugly fit over the deltoid area. This cup is webbed to the shoulder pad proper, and an epaulet is added directly over the cup for extra protection. When fit is poor, the cup will hang down the arm and cause a potential bruise from the cap's edge, or a cap will dangle in space and not be protected by the epaulet. To protect the lower ribs, a separate set of rib pads is most helpful.

The shoulder pad proper is secured in position by an extension strap, pulled snug to prevent rotation. The strap runs from the back, under the armpit, and is hooked in front. Tension too severe will cause wearing of the steel straps and pull the pad out of proper position.

Hip, Thigh, Knee, and Leg Protection

In many sports, good protection is needed for the hips, thighs, knees, shins, and ankles. Protection should be fairly comfortable, nonslip, light-weight, nonabrasive, nonperspiration absorbing, allow freedom in movement, yet provide adequate support and protection.

A good hip pad should protect the posterior iliac spines and sacrococcygeal area, the trochanteric bursae and entire iliac crest laterally, and the anterior iliac spines in front, if painful injuries are to be prevented. In football, the "pro" type of hip pads are usually too light to afford the protection necessary. As bulk at the waist decreases speed, most athletes have a bad tendency to wear their hip pads too low. Hip pads worn too low also force an improper position on the shell pant and thigh pad.

Thigh and knee pads cannot do what they are designed to do if the pants are improperly fitted. A loose fit allows the thigh and knee pads to slide about, and external taping rarely can make proper compensation. The knee pad used in volleyball, for instance, must be slick so that impact force can be reduced by sliding. In such sports as hockey, rugby, and soccer, shin guards are important. It is highly advised that basketball players wear long socks to help protect the legs from kicks suffered near the basket.

Footwear and Foot Protection

There is great need for the improvement in the design of sports footwear to provide greater safety and efficiency. Athletic footwear should possess three main features: good shock-absorbing characteristics, good traction features, and good lateral support under stress. Keep in mind that jogging creates vertical forces from two to four times body weight.

While "low cut" models of football shoes have become popular because they are lighter and allow greater speed, the older "high top, high lace" type affords added protection against ankle injuries. In track, emphasis has been on shoe lightness at the expense of firm soles and freedom of toe movement. Special orthotic devices are often required. Repeated hard trauma has an especially injurious influence during childhood and youth.